Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 2
Description: Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.
(Medical Transcription Sample Report)
SUBJECTIVE: Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable.
OBJECTIVE: Her blood pressure is 110/60. Other vitals are stable. HEENT: Unremarkable. Neck: Unremarkable. Lungs: Clear. Heart: Regular. Abdomen: Unchanged. Extremities: Unchanged. Neurologic: Unchanged.
1. NIDDM with improved control.
3. Coronary artery disease status post coronary artery bypass graft.
4. Degenerative arthritis.
7. Renal azotemia.
9. Fibroglandular breasts.
PLAN: We will get follow-up labs today. We will continue with current medications and treatment. We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY. The patient is advised to proceed with previous recommendations. She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed.
Keywords: general medicine, accu-chek, heent: unremarkable, hyperlipidemia, hypertension, lungs: clear, niddm, neck: unremarkable, progress note, soap, coronary artery bypass graft, follow-up labs, glucose monitoring, coronary artery,